Connor Sparrowhawk: Southern Health accepts responsibility for his death

Sanchita Hosali

10 June 2016

Connor Sparrowhawk was, in the words of those who campaigned for an investigation into his preventable death, “a fit and healthy young man, who loved buses, London, Eddie Stobart and speaking his mind. He lived in Oxford and was in the sixth form of a local special school. [He] was diagnosed with autism, learning disabilities and epilepsy.” In tragic cases of preventable deaths such as Connor’s, our Human Rights Act provides an important tool for families and loved ones to seek accountability. Yesterday, following the inquest into Connor’s death, Southern Health NHS Foundation Trust, who had been entrusted with his care, accepted full responsibility for Connor’s death, admitting it violated both his and his family’s human rights.

What happened to Connor?

In March 2013, following changes in his mood, Connor was admitted to Slade House, a small inpatient unit for people with learning disabilities in Oxfordshire, run by Southern Health NHS Foundation Trust. The unit stated in Connor’s care plan that he would be checked on every 15 minutes while bathing, but subsequent investigations found no evidence that such checks took place. Connor was found submerged in a bath on 4 July 2013, and died in hospital a short time later. Although the Trust initially suggested that Connor had died of natural causes, both Connor’s family and independent regulators had concerns about care and treatment standards at Slade House.

What did the regulators find?

In September 2013, England’s regulator of health and social care, the Care Quality Commission (CQC) inspected the unit Connor had been staying in, and spoke to three of the five people staying there. The inspection report states that “[o]ne person told us they felt unsafe and uncared for, another told us they ‘hated it’ there. The third person said ‘It is okay.’” The report further found that “[o]ver the course of two days, we saw few social or therapeutic nursing interactions with people who stayed there. There appeared to be an impoverished environment with little therapeutic intervention or meaningful activities to do.” The CQC undertook a number of enforcement actions following the September inspection, and visited the unit again in December 2013, and found improvements had been made.

The importance of human rights

Our Human Rights Act pulls down 16 fundamental rights from the European Convention on Human Rights and makes them part of our law here at home, placing duties on public authorities to respect, protect and fulfil these rights. One of these rights is the right to life (Article 2), which means public authorities must take reasonable steps to protect a person’s life when it is known to be at risk. In addition, this human right also means there must be an investigation when a person dies in circumstances in which public officials or authorities may be implicated or involved. Often this means holding an inquest to investigate what has happened.

The inquest

Following his death, Connor’s mother Sara Ryan worked with specialist charity INQUEST, and launched her own campaign, Justice for LB (LB, referring to Connor’s nickname Laughing Boy). Justice for LB has called for, among many other things, “[m]eaningful involvement at the inquest, and any future investigations into LB’s death, so we can see the Trust and staff account for their actions in public.”

The inquest began in October 2015, and the jury found that Connor drowned in the bath following an epileptic seizure. The jury also found that neglect contributed to his death, specifically in relation to a lack of leadership at the unit and risks around Connor’s epilepsy. The latter included failure to take an adequate history of his condition, failure to conduct risk assessments appropriately, and failure to communicate with his family, with whom he had lived until his admission, about how best to manage his epilepsy.

Accepting responsibility for human rights failures

Yesterday, 9 June 2016, Southern Health NHS Foundation Trust admitted that it breached Connor Sparrowhawk’s human rights, and that its failures caused his death. More specifically, the Trust accepted that it breached Connor’s right to life (Article 2), as well as the rights of his family, and agreed to pay compensation for its omissions. The Trust’s full statement can be read here. The Human Rights Act was vital in ensuring that Connor’s family was able to find out how and in what circumstances he died, through a process in which they could participate.

The future

The issue in this case is much greater than one young boy’s tragic and preventable drowning. The Justice for LB campaign argues that justice “for all the young dudes” would include critical reflection on regulation of facilities like Slade House, changes to use of the Mental Capacity Act, and, crucially, “proper informed debate about the status of learning disabled adults as full citizens in the UK, involving and led by learning disabled people and their families, and what this means in terms of service provision in the widest sense and the visibility of this group as part of ‘mainstream’ society.” Here at the British Institute of Human Rights we aim to achieve this through our frontline projects in mental health and mental capacity. We work directly with individuals, their advocates and service providers to demonstrate how the Human Rights Act can be used to develop rights-respecting services. Yesterday’s admission by the Southern Health is a further small but significant step in this direction.

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